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Salud Pública de México
ISSN: 0036-3634
[email protected]
Instituto Nacional de Salud Pública
México
Hernández-Ávila, Juan Eugenio; Palacio-Mejía, Lina Sofía; González-González, Leonel;
Morales-Carmona, Evangelina; Espín-Arellano, Lucino Iván; Fernández-Niño, Julián
Alfredo; Mohar-Betancourt, Alejandro; Hernández-Ávila, Mauricio
Utilization of hospital services for cancer care in Mexico
Salud Pública de México, vol. 58, núm. 2, marzo-abril, 2016, pp. 142-152
Instituto Nacional de Salud Pública
Cuernavaca, México
Available in: http://www.redalyc.org/articulo.oa?id=10645277007
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Hernández-Ávila JE y col.
Artículo original
Utilization of hospital services
for cancer care in Mexico
Juan Eugenio Hernández-Ávila, DSc Epid,(1) Lina Sofía Palacio-Mejía, D Pop Stud,(1) Leonel González-González, D Soc Sci,(1)
Evangelina Morales-Carmona, M GIS Mgmt,(1) Lucino Iván Espín-Arellano, B Comp Sc,(1) Julián Alfredo Fernández-Niño, MSc
Biostat,(1) Alejandro Mohar-Betancourt, MD, DSc,(2) Mauricio Hernández-Ávila, DSc.(3)
Hernández-Ávila JE, Palacio-Mejía LS,
González-González L, Morales-Carmona E,
Espín-Arellano LI, Fernández-Niño JA,
Mohar-Betancourt A, Hernández-Avila M.
Utilization of hospital services
for cancer care in Mexico.
Salud Publica Mex 2016;58:142-152.
Hernández-Ávila JE, Palacio-Mejía LS,
González-González L, Morales-Carmona E,
Espín-Arellano LI, Fernández-Niño JA,
Mohar-Betancourt A, Hernández-Avila M.
Utilización de los servicios hospitalarios
para la atención del cáncer en México.
Salud Publica Mex 2016;58:142-152.
Abstract
Resumen
Keywords: neoplasm; utilization; health services; patient
discharge; Mexico
Palabras clave: neoplasia; utilización; servicios hospitalarios;
egreso hospitalario; México
Objective.To analyze the utilization of hospital services for
cancer care by location, sex, age group and care institution in
Mexico from 2004-2013. Materials and methods.Time
series study from 2004-2013, based on administrative records
of hospital discharges for cancer in the health sector, including
the private sector. Results. The utilization rate increased
significantly from 290 to 360 per 100 000 inhabitants.A total
of 62% of hospital discharges related to malignant tumors
were concentrated in eight types of cancer. Leukemia, breast
and colorectal cancers almost doubled in the period. While
lung cancer showed a decline among men, it increased among
women. A total of 63.1% of cancer patients were women, and
81% of cases occurred in the public sector. From 2011, the
Ministry of Health was the main provider of hospital services
for cancer care. Conclusions. Increases in utilization were
mainly found in the Ministry of Health, quite possibly as a
result of the implementation of universal insurance.
Objetivo. Analizar la utilización de servicios hospitalarios
para la atención del cáncer según localización, sexo, grupo
de edad e institución de atención en México de 2004 a
2013. Material y métodos. Estudio de serie de tiempo
de 2004-2013, de registros administrativos de egresos hospitalarios por cáncer del sector salud, incluyendo el sector
privado. Resultados. La tasa de utilización incrementó
significativamente de 290 a 360 por 100 000 habitantes.
El 62% de egresos hospitalarios por tumores malignos se
concentró en ocho tipos. La leucemia, cáncer de mama y de
colon y recto casi se duplicaron en el periodo. El cáncer de
pulmón muestra un descenso en hombres mientras que en
las mujeres sigue aumentando; 63.1% fueron mujeres. El 81%
ocurrió en el sector público. A partir de 2011 la Secretaría
de Salud fue el principal productor de servicios hospitalarios
para la atención del cáncer. Conclusiones. El aumento en
la utilización se dio principalmente en la Secretaría de Salud
muy posiblemente como resultado de la implementación del
Seguro Popular.
(1) Centro de Información para Decisiones en Salud Pública, Instituto Nacional de Salud Pública. Ciudad de México, México.
(2) Instituto Nacional de Cancerología. Ciudad de México, México.
(3) Instituto Nacional de Salud Pública. Cuernavaca, México.
Received on: August 25, 2015 • Accepted on: November 4, 2015
Corresponding author: Dra. Lina Sofía Palacio Mejía. Instituto Nacional de Salud Pública. Av. Universidad 655,
col. Santa María Ahuacatitlán. 62100 Cuernavaca, Morelos, México.
Email: [email protected]
142
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Hospitalization for cancer in Mexico
T
he use of hospital discharge records to measure
the utilization of health services has proven useful
in other countries.1,2 In Mexico, there have been some
studies on the costs of cancer care using hospital discharge records,3 along with studies to assess hospital
performance.4-6
Given the absence of a national cancer registry in
Mexico and limited information on the use of hospital
services for the care of this disease in the Mexican health
system, a study of the sources of information available
in the country is needed in order to develop indicators
to assess the trend of services utilization in the Mexican
population. The aim of this paper is to analyze the use
of hospital services for cancer care in Mexico by tumor
location, sex, age and care institution in the period
2004 to 2013 through hospital discharge administrative
records in the health sector.
Materials and methods
A time series study over the period 2004-2013 was
performed to analyze the use of hospital services in
Mexico. This analysis was achieved through the use
of databases with information on hospital discharges
by cancer location, sex, age group and care institution
that have been generated by the Mexican health sector,
including the private sector.
According to the Official Mexican Standard 035SSA3-2012, hospital discharge is defined as “the event
wherein the patient is released from in-patient services
involving the vacation of a hospital bed. It includes
discharges for cure, improvement, transfer to another
hospital unit, death, voluntary discharge or flight and
excludes movements between different services within
the hospital.”7 It is important to consider that while
hospital discharge records compile data for each event,
a person can be admitted to the hospital on different
occasions for the same cause or for various reasons in
the same period.
Source of information
Hospital discharges in the public sector. Public sector discharge records were obtained from a standard-format
database of hospital discharges in the health sector
(2004-2013), which is available on the website of the
National Health Information System (Sistema Nacional de
Información en Salud - SINAIS) of the Directorate General
of Health Information (Dirección General de Información
en Salud - DGIS).8 This database included more than 51
million hospital discharge records during the evaluated
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Artículo original
period and provided basic information such as year of
care, sex, age of patient, and main condition. The records
are coded according to the International Classification
of Diseases ICD-10,9 length of stay, reason for discharge
and hospital discharges from the care institution produced by the Ministry of Health, the Mexican Social Security Institute (Instituto Mexicano del Seguro Social - IMSS),
Oportunidades IMSS, the Institute for Social Security and
Services for State Workers (Instituto de Seguridad Social
y Servicios para Trabajadores del Estado - ISSSTE), Pemex
and the Mexican Navy.
Private sector hospital discharges. Private sector discharge
records were obtained by dynamic queries of health statistics from private establishments on the website of the
National Institute of Statistics and Geography (Instituto
Nacional de Estadística y Geografía - INEGI) for the period
2004 to 2013. The hospital discharge variables recorded
consisted of the principal discharge diagnosis, sex, days
of stay and deaths and were disaggregated nationally,
by state and by group of causes.10
Selection of causes of hospital discharge
associated with cancer
Hospital discharges for cancer were selected according
to the variable main condition, coded as malignant
tumors C00-C97, based on the ICD-10. The discharges
were grouped according to the 2004 Global Burden of
Disease classification system.11,12 On the basis of this
classification, the causes were analyzed as follows: 1.
Leukemia (C91-C95), 2. Breast (C50), 3. Lymphomas
and Multiple Myeloma (C81-C85, C88, C90), 4. Cervix
(C53), 5. Colorectal (C18-C21), 6. Ovary (C56), 7. Trachea,
Bronchus and Lung (C33 and C34), 8. Prostate (C61),
and 9. Other malignant tumors.
Hospital discharges were analyzed by cancer location, year of occurrence, sex, age groups (under 15 years,
15 to 64 years and 65 years and over) and service provider institution (SSa / Sesa IMSS Oportunidades, IMSS,
ISSSTE, Pemex and the Mexican Navy). For the private
sector, it was only possible to perform an analysis of the
location of the cancer because the data available were
aggregated and data inconsistencies were detected in
the breakdown by sex and age.
Indicators of utilization of services were calculated
as follows:
Total hospital discharges. The total discharge number was
the sum of hospital discharges by tumor location, sex,
age and institution that occurred in each year of the
study period.
143
Artículo original
Hernández-Ávila JE y col.
Proportion of discharges:
Given that it was not possible to define the affiliated population or users of each institution properly in
the health sector and that users transition dynamically
between different institutions in terms of eligibility and
also turn to private services, the analysis presented in
this document refers to the comparison of the absolute
numbers and proportions observed by institution, age
and sex for each tumor type.
An analysis was completed to determine the quality of data sources used that included the calculation of
the percentage of causes coded as “ill defined”, along
with the percentage of missing values in the variables
of interest. Finally, the percentage of records coded as
tumors of uncertain or unknown behavior was calculated.
The databases were manipulated in the MS-SQL
Server,* and statistical calculations in Tableau 9.0.‡
∑ discharge by groupj,k
Proportion of dischargesj,k ––––––––––––––––––––––––
∑ dischargesj
where j represents each of the studied variables: tumor
location, sex, age group and institution; k represents
their respective categories.
Days of Stay. The days of stay were defined as the ‘number of days elapsed from patients’ admittance to in-patient services up to discharge.’ This number is obtained
by subtracting the date of discharge from admittance.
When the patient is admitted and is discharged on the
same day, occupying a hospital bed, it counts as a day
stay. A zero-day stay is recorded when the patient is seen
exclusively on short stay services because these services
have not used a hospital bed.
Total days of stay. The total days of stay represents the
sum of days of stay by tumor location, sex, age and
institution occurring in each year of the study period.
Average days of stay:
Total days of stayj,k
Average days of stayj,k ––––––––––––––––––––––––
dischargesj,k
where j represents each of the variables studied: tumor
location, sex, age group and institution; k represents
their respective categories.
Intrahospital mortality. This number represents the total
discharges due to death from cancer among total hospital discharges by cancer type.
Overall rate of the utilization of hospital services. The rate of
utilization is calculated from the total hospital discharges from each institution, including the private sector, as
the numerator, divided by the total population per year
during the study period (according to estimates by the
Consejo Nacional de Población - Conapo)13 as the denominator. To make a comparison with statistics generated
by the Organization for Cooperation and Economic
Development (OECD),14 all of the discharges in relation
to cancer care were included in the numerator, i.e., malignant neoplasms (C00-C97), tumors in situ (D00-D09),
benign tumors (D10-D36) and tumors of uncertain or
unknown behavior (D37-D49), although the results are
presented for one hundred thousand inhabitants.
To analyze trends in the overall rate of hospital services utilization and the rate based on the location of the eight
most important tumors, regression models with time series
cross-sectional data were employed using marginal linear
models (time series cross-sectional data analysis).15 The
utilization rate was converted using the natural logarithm.
144
Results
The hospital services utilization rate for cancer in Mexico
showed an annual increase of 2.19% (p<0.001, 95% confidence interval [CI] [1.88-2.49]), from 318 237 discharges in
2004 to 428 913 discharges in 2013, with an overall hospital
services utilization rate of 300 discharges per one hundred
thousand inhabitants in 2004 to 360 in 2013 (figure 1).
In 2013, 62% of the hospital care of malignant tumors
focused on eight types of cancers: leukemia, breast, lymphoma and multiple myeloma, cervix, colorectal, ovary,
trachea, bronchus and lung and prostate. During the
2004-2013 period, the annual utilization rates for these
eight tumors increased significantly for all but cervical,
prostrate and trachea, bronchus and lung cancers. The latter decreased significantly by 1.8% (p≤0.001, 95%CI [-2.4,
-1.2]), and its utilization rate in 2013 was 5.7 per one hundred thousand inhabitants. In the same year, the colorectal
cancer rate ranged between 8.0 and 14.4 discharges per
one hundred thousand inhabitants and showed an annual
percentage increase of 7.2% (p<=0.001, 95%CI [6.4-8.1]);
the breast cancer rate ranged between 36.0 and 61.8 per
one hundred thousand women, with an increase of 7.0%
(p<=0.001, 95%CI [5.9]); leukemia increased from 18.1 to
29.1 per one hundred thousand inhabitants in increments
of 5.3% (p<=0.001, 95%CI [4.2-6.5]); lymphomas and multiple myeloma increased from 12.0 to 16.3 in increments of
3.2% (p<=0.001, 95%CI [2.6-3.7]); ovarian cancer increased
from 13.3 to 14.3 in increments of 1.7% (p<=0.001, 95%CI
[1-2.5]); and prostate cancer increased from 15.3 to 15.5, in
increments of 0.3% (p<=0.3, CI95% [-0.2-0.7]). The utiliza* Microsoft. SQL Server 2012. Available from: http://www.microsoft.
com/es-es/server-cloud/products/sql-server/.
‡
Tableau Software. Tableau Desktop 9.0. 2014.
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Hospitalization for cancer in Mexico
Artículo original
accounted for 36.7% of total discharges for the eight
main types of cancer. Figure 2 shows that the highest
increases occurred between 2009 and 2012. The use of
colorectal cancer care services increased 121.3% in the
period, representing the tumor with the highest percentage among women; in 2013, 8% of discharges were
related to colorectal cancer. The utilization of services for
leukemia among women almost doubled in the period
(98.9%) and was the most frequent reason for hospital
service utilization among men, causing an increase of
75.9% in the period. This condition accounted for 17.6%
of discharges among women and 39.1% among men.
However, just as among women, for men, the largest
percentage increase in utilization was due to colorectal
cancer care, with an average growth of 134.2% with
respect to its value in 2004; in 2013, the utilization for
this type of tumor accounted for 17.0% of discharges
and became the third most common category. The
Calendar year
Utilization rate
2013
2012
2011
2012
2009
2008
2007
2006
2005
2004
0
2013
2012
2011
2012
2009
2008
2007
2006
2005
2004
0
20
100
Utilization rate per 100 000
40
60
Utilization rate per 100 000
200
300
80
400
tion rate for cervical cancer varied between 25.3 and 26.4
per one hundred thousand women, with a non-significant
increase of 0.3% (p<=0.8, 95%CI [-2.7-3.5]). However, our
results show that the rate had been declining until 2009,
after which it began an upward trend (figure 1).
The results by sex, age group and institution are
exclusively represented by the public sector, with absolute increases and proportions, because of difficulties in
defining the user population.
In the last ten years, it has been observed that hospital
services utilization for cancer care in the public sector was
higher among women, with an approximate ratio of two
women per man, a rate that was maintained throughout
the evaluation period, resulting in 65.4% of discharges
among the female population in 2013 (figure 2).
The utilization of breast cancer services was highest
among women and showed an increase of 114.9% over
the period studied. Furthermore, in 2013, this category
Calendar year
95% confidence interval
Colorectal
Tracheal
Breast
Ovarian
Prostate
Lymphoma
Cervical
Leikemia
95% confidence interval
Source: calculations are based on hospital discharges in the public health sector, DGIS / SSA 2004-2013,8 and discharges from the hospitals in the private
sector, INEGI, 2004-201310
Figure 1. Overall rate of hospital service utilization and the eight most important tumors
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
145
Hernández-Ávila JE y col.
Artículo original
Men
33K
Women
38.3%
36.7%
30K
37.3%
27K
36.0%
24K
21K
Hospital discharges (in thousands)
33.4%
18K
38.2%
39.1%
29.7%
30.1%
39.8%
15K
39.0%
29.2%
37.2%
37.7%
29.2%
17.7%
17.5%
29.8%
16.8%
17.3%
37.3%
36.8%
12K
18.3%
23.1%
19.9%
36.1%
34.2%
20.4%
9K
6K
22.7%
22.6%
17.5%
16.2%
3K
17.0%
22.1%
13.5%
13.0%12.0%
11.2%
11.1%
15.4%
12.2%
15.3%
15.3%
15.2%
12.8%
11.8% 11.0%
17.0%
14.5%
15.4%
15.2%
13.8%
12.9%
12.1%
10.0%
9.5%
12.0%
10.5%
8.1%
11.3%
11.1%
10.6%
10.3%
6.8%
8.8%
9.2%
2.6%
0.9%
0.0%
0.8%
0.8%
0.6%
2005
2007
0.7%
0.7%
7.3%
6.2%
4.1%
7.1%
2009
1.0%
2011
11.4%
11.2%
11.0%
10.6%
10.7%
7.6%
7.0%
2005
2007
9.3%
9.4%
8.8%
8.0%
7.6%
7.0%
3.2%
3.6%
3.7%
9.6%
7.4%
6.4%
4.1%
9.4%
10.0%
10.3%
3.4%
2.9%
2.8%
3.0%
1.8%
0.9%
Calendar year
14.9%
14.3%
16.6%
3.9%
0K
17.1%
15.2%
14.2%
10.3%
15.0%
19.4%
15.0%
20.8%
23.0%
16.0%
17.9%
20.2%
22.3%
22.1%
23.2%
20.6% 18.1%
21.8%
20.1%
0.0%
2013
2009
Calendar year
2011
II.A.04 Colorectal
II.A.07 Trachea, bronchial and lung
II.A.09 Breast
II.A.10 Cervical
II.A.12 Ovarian
II.A.13 Prostate
II.A.15 Lymphoma and multiple myeloma
II.A.16 Leukemia
2013
Source: based on hospital discharges in the public health sector, DGIS / SSA, 2004-20138
Figure 2. Total and annual proportions of hospital discharges by sex for the eight most important
cancers
service utilization rates for lymphomas and multiple
myeloma and prostate cancer rose by 47.7% and 21.4%,
respectively, while care for malignant tumors of the
trachea, bronchus and lung in men decreased by 17.2%,
in contrast to what was observed in women, for whom
care increased by 15.2% (figure 2).
146
Childhood cancer care (under 15 years) accounted for
16.8% of all hospital discharges of care for the eight main
cancers in the public sector during the study period. Care
for the 15- to 65-year-old population category accounted
for 60.6%, and care for the elderly (65 years and older)
accounted for 22.6% of total discharges (figure 3).
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Hospitalization for cancer in Mexico
Artículo original
Men
Women
Less than 15 years
Hospital discharges (in thousands)
10K
8K
6K
4K
2K
0K
26K
24K
15 to 64 years
Hospital discharges (in thousands)
22K
20K
18K
16K
14K
12K
10K
8K
6K
4K
2K
0K
65 years and older
Hospital discharges (in thousands)
6K
4K
2K
0K
2005
2007
2009
2011
2013
2005
Calendar year
2007
2009
2011
2013
Calendar year
II.A.04 Colorectal
II.A.07 Trachea, bronchial and lung
II.A.09 Breast
II.A.10 Cervical
II.A.12 Ovarian
II.A.13 Prostate
II.A.15 Lymphoma and multiple myeloma
II.A.16 Leukemia
Source: based on hospital discharges in the public health sector, DGIS / SSA, 2004-20138
Figure 3. Total and annual proportions of hospital discharges by sex and age group for the eight
main types of cancer
Utilization of inpatient care for leukemia accounted
for 87.6% of all discharges among patients under 15 years
old, while lymphoma and multiple myeloma accounted
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
for 10.4%. Discharges for leukemia doubled in this age
group (107.4%), and those for lymphomas increased by
50.0% in the past decade (figure 3).
147
Artículo original
The utilization of hospital services among women
15 to 64 years of age was primarily due to care for breast
cancer (31.1%), cervical cancer (20.4%) ovarian cancer
(11.9%), leukemia (9.6%), lymphoma and multiple
myeloma (9.5%), and colorectal cancer (6.9%). Among
men 15 to 64 years of age, the main causes for hospital
utilization were lymphoma and multiple myeloma
(30.1%), leukemia (29.6%), colorectal malignant tumor
(19.9%), cancers of the trachea, bronchus and lung (9.5%)
and prostate cancer (9.1%). For both sexes in this age
group, the main increases were for colon cancer (130.6%)
followed by breast cancer (105.7%), leukemia (59.5%),
lymphoma and multiple myeloma (53.3%), prostate
cancer (50.7%), and cervical cancer (24.0%), while utilization for malignant tumors of the trachea, bronchus
and lung decreased (1.6%). The utilization of hospital
services by these types of cancer in men decreased by
12.9% in 2013 compared to 2004, whereas in women, an
increase of 15.7% (figure 3) was observed.
The most common causes of cancer care in patients
over 65 years of age were breast cancer (18.4%), prostate
cancer (18.3%), lymphomas and multiple myeloma
(15.9%), colorectal cancer (14.4%), and cancers of the
trachea, bronchi and lung (13.6%) (figure 3). In patients
over 65 years of age, the fastest growing use of hospital services was for breast cancer, with an increase of
142.7%, followed by colorectal cancer (91.4%), leukemia
(66.4%) and lymphoma and multiple myeloma (53.1%),
while use of services for cancers of the trachea, bronchus and lung decreased by 12.4% (figure 3). In men in
this age group, utilization decreased by 22.2%, while it
increased by 10.6% in women (figure 3).
Our results, by care institution, show that during
the 2004-2013 period, 81% of discharges occurred in
public sector institutions and that 19% occurred in the
private sector. Cancer care in the public sector was the
origin of almost 6% of all discharges, ranking third in
importance, while in the private sector, cancer care was
ranked seventh in importance, based on number of
discharges and patient days, respectively.
The IMSS was the largest provider of inpatient
services, with 38.2% of hospital discharges constituting
care for eight major cancers, followed by the SSa and the
Sesa, which provided 35.7% in the period. However, in
the Ministry of Health, the annual provision of hospital
services increased from 25 837 discharges in 2004 to 65
551 in 2013 (26.8 and 44.1% of the total annual provision,
respectively). With an average annual growth of 18.4%
from 2011, the SSa and the Sesa combined represent
institutions in the health sector with greater discharge
outputs for cancer in Mexico. In 2013, this statistic
was reflected by an increase of 153.7% over 2004. In
the IMSS and the private sector, the annual increases
148
Hernández-Ávila JE y col.
in the number of discharges were only 2.1 and 0.5%,
respectively (figure 4).
In the ISSSTE, an increase of 45.5% was observed
in 2004, with discharges rising from 7 086 in that year
to 10 307 in 2013. The participation of the private sector
in the care of the eight main cancers has been reduced
by one-third, decreasing from 18.3 in 2004 to 12.8 in
2013 (figure 4).
Regarding the motives for discharge, 83.5% of hospital discharges for the care of the eight main cancers involved discharging the patient because of improvement,
4.9% for healing, 5.3% for bereavement and 5.9% for other
reasons. The causes that increased intrahospital mortality
as determined by the study were leukemia (24.3%), malignant tumors of the trachea, bronchus and lung (17.1%),
lymphomas and multiple myeloma (15.3%), breast cancer
(12.2%), and colorectal cancer (10.3%). The intrahospital
mortality among patients with trachea, bronchus and
lung cancer was 15.5%, three times greater than what was
observed for prostate cancer, leukemia, and lymphoma
and multiple myeloma and five times greater compared
to women discharged for breast cancer.
The eight main cancers produced 5 911 225 days
of stay and more than a third of the total discharges
for cancer. In total, 34.0% were due to leukemia, 17.0%
to lymphoma and multiple myeloma, 11.9% to breast
cancer, 11.4% to malignant colorectal tumor, 8.2% to
cervical cancer, 7.2% to cancers of the trachea, bronchus
and lung, 5.5% to malignant ovarian tumors, and 4.9%
to malignant tumors of the prostate.
The average length of stay because of leukemia was
7.9 days; 50% of discharges recorded lasted between
1 and 9 days (interquartile range), and 25% were 9 or
more days (75th percentile). A total of 5% of discharges
had durations of 30 or more days (95th percentile).
The average length of care for malignant tumors of the
trachea, bronchus and lung was 7.3 days. However,
the interquartile range (2-9) had a higher lower limit
than that of leukemia, as reflected in the micrographs
accompanying table I. Overall, the average length of stay
for the care of the eight major cancers was 5.9 days, and
the 95th percentile was 21 days (table I).
Based on proportions of hospital discharges, care
for malignant tumors mainly occurred in the Federal District (27.3%), Jalisco (8.7%), Veracruz (6.6%),
Michoacán (6.5%) and Nuevo León (5.5%). Between
2009 and 2013, 1263 hospitals reported at least one
discharge in the public sector related to malignant
tumors; however, 70% of these discharges occurred in
84 hospitals. The ten main hospitals that produced 30%
of the discharges were the State Center for Cancer Care
in Morelia SSa / Sesa, Michoacan, with 53 500 discharges in the period, followed by the Jalisco Institute of
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Hospitalization for cancer in Mexico
Artículo original
44.2%
65K
43.2%
60K
41.1%
55K
33.6%
50K
38.0%
33.5%
35.4%
37.3%
39.8%
45K
Hospital discharges (in thousands)
41.1%
44.3%
43.5%
38.7%
39.9%
35.0%
40K
32.2%
35K
30.8%
29.5%
30K
27.8%
25K
26.9%
20K
13.6%
18.1%
18.7%
17.9%
18.3%
12.7%
15.4%
16.5%
14.0%
13.2%
15K
10K
7.5%
8.2%
8.4%
8.5%
7.1%
6.9%
7.8%
8.1%
7.4%
7.3%
5K
2.4%
2.2%
0K
0.4%
0.5
2004
SSa/SESA
2.0%
0.4%
2005
2.2%
0.5%
2006
IMSS
0.4%
2007
2.0%
2.0%
0.5%
0.4%
2008
IMSS-OP
2009
ISSSTE
2.2%
2.1%
0.5%
0.3%
0.4%
2010
2011
2012
PEMEX
1.8%
Mexican Navy
2.0%
0.4%
2013
Private sector
Source: calculations are based on hospital discharges in the public health sector, DGIS / SSA 2004-2013,8 and discharges from the hospitals in the private
sector, INEGI, 2004-201310
Figure 4. Total and annual percentages of hospital discharges by institution providing the services.
Mexico, 2004-2013
Oncology SSa / Sesa (37 753), the Oncology Hospital of
the Siglo XXI National Medical Center IMSS in Mexico
City (36 557), the National Cancer Institute SSa / Sesa
in the Federal District (33 055), the Specialties Hospital
IMSS HES25 in Nuevo León, Monterrey (28 777), the
General Hospital of Mexico of the SSa / Sesa in the
Federal District (28 639), the Specialties Hospital HES
of IMSS (23 301), the Children’s General Hospital Eva
Samano Lopez Mateos in Morelia, Michoacan (18 196),
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
the “20 of November” hospital, ISSSTE in Mexico City
(17 125) and the Centenario Hospital Miguel Hidalgo
from the Ministry of Health in Aguascalientes (16 004).
Regarding the quality of information, 1.4% of all
hospital discharges were coded as ill-defined, and less
than 1% of the records had unspecified values in key
analysis variables: sex, age, insurance eligibility and
motive of discharge. Likewise, hospital discharges in
which the main condition was coded within the group
149
Hernández-Ávila JE y col.
Artículo original
Table I
Discharges and duration of stay by main types of cancer. Mexico, 2004-2013
Discharges
Patient
days
% Patient
days
Mean
P 25
Median
P 75
P 95
80K
II.A.16.x. Leukemia
255 821
2 010 118
34.0%
7.9
1
4
9
30
Less than 15 years
15 to 64 years
65 years and older
60K
40K
20K
0K
80K
II.A.09.x. Breast
219 041
700 593
11.9%
3.2
1
2
3
10
60K
40K
20K
0K
80K
60K
II.A.15.x.
Lymphoma and
multiple myeloma
146 882
1 002 390
17.0%
6.8
2
4
8
22
II.A.10.x. Cervical
108 789
483 680
8.2%
4.5
1
3
5
14
40K
20K
0K
80K
60K
40K
20K
0K
80K
II.A.04.x.
Colorectal
60K
97 683
671 009
11.4%
6.9
2
4
9
21
40K
20K
0K
80K
II.A.12.x. Ovarian
67 003
327 955
5.5%
4.9
2
3
6
15
60K
40K
20K
0K
80K
II.A.07.x. Tracheal,
bronchial and lung
60K
58 783
426 725
7.2%
7.3
2
5
9
23
40K
20K
0K
80K
II.A.13.x. Prostate
57 203
288 755
4.9%
5.1
2
3
6
15
60K
40K
20K
0K
Total
1 011 205
5 911 225
100.0%
5.9
1
3
7
21
250K
200K
150K
100K
50K
2
of cancers as uncertain or unknown behavior accounted for 11.4% of total discharges resulting from cancer
care in the public sector.
Discussion
Our results indicate that there has been a significant
increase in the use of hospital services for cancer care in
Mexico in the last ten years, with a hospitalization rate for
cancer of 360 discharges per one hundred thousand inhabitants in 2013. This rate is higher than the value reported
by the OECD of 300,14,16 as the information reported by this
agency does not consider hospitalizations in the private
sector.14 According to the World Health Organization
(WHO)17 and the OECD,14 Mexico is among the countries
150
8
14
20
26
32
38
44
with the lowest cancer incidence in the region and with
the lowest hospitalization rate from the member countries
of the OECD, followed by the United States.16
More than sixty percent of hospital discharges for malignant tumors in Mexico were related to the care of eight
types of cancer: breast malignancy; leukemia; lymphoma
and multiple myeloma; colorectal, cervical, ovarian, and
prostate cancers; and malignant tumor of the trachea,
bronchi and lungs, the majority of which were included
in the catastrophic expenses funds CAUSES 2014.18 The
most significant increases in the rate of utilization were
for colorectal cancer, breast cancer and leukemia, which
nearly doubled the number of discharges in the period
studied. These diseases are among the cancers with the
highest mortality rates in Mexico.
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Hospitalization for cancer in Mexico
The increase in discharges for colorectal cancer coincides with increased mortality of the disease in adults and
the elderly, in addition to the estimated increase in the
proportion of deaths from this cancer worldwide, which
increased from 0.47% in 1999 to 0.85% in 2010 in both sexes.19,20 According to reports published by the Department
of Epidemiology of the SSa, the incidence of breast cancer
increased 289% between 2000 and 2013, surpassing 3.72
to reach 10.76 cases per 100 000.21 The use of hospital services to care for tumors of the trachea, bronchus and lung
showed differential changes. While a decrease was noted
among men during the period, the incidence increased
among women. Limitations with the data remained, and
it was not possible to test the hypothesis of differences.
However, the findings conformed to mortality data observed and could be a reflection of the different degrees
of progress made in controlling the epidemic of smoking
among men and women in Mexico.22
The use of hospital services for cancer care was the
highest among women, especially for breast cancer, leukemia and cervical cancer. Women in the 15- to 64-year
old age group accounted for almost half of all discharges
produced by public sector institutions; this rate coincides
with the various explanatory models on the increased use
of health services for women.23 Additionally, the rate was
associated with the increased reporting of breast cancer
among women; more than 80% of these cases are identified in advanced stages.24 In men, the leading causes of
hospital services utilization were leukemia, lymphomas
and cancers of the colon and rectum and prostate.
The leading causes of hospitalization in children under 15 years were largely leukemia, distantly followed by
lymphoma and multiple myeloma and liver cancer. This
incidence coincides with what was reported by the Ministry of Health for the period 2005-2010, where the largest
proportion of cancer cases in children under 20 years was
leukemia, with the 10- to 14-year-old age group the most
affected.25 From 2005 and 2010, the Ministry of Health
reported that leukemia contributed to almost half of all
deaths by malignant tumors in this age group (49.7%).25
During the study period, the IMSS produced the
majority of hospital discharges for the care of the eight
major cancers. However, the provision of inpatient services in the SSa/Sesa increased beginning in 2011, which
resulted in the SSa/Sesa becoming the institution with
the highest production of hospital discharges in Mexico.
This finding is most likely a result of expanded coverage
and accessibility under the implementation of the System
of Social Protection in Health, which is provided to the
low-income population.26 An increase in the utilization of
hospital services for cancer care was also observed in the
ISSSTE. With a relatively stable population, the observed
increase may be a reflect of an ageing population.
salud pública de méxico / vol. 58, no. 2, marzo-abril de 2016
Artículo original
While the available data are limited with respect to
generating general statistics, absolute and proportional
changes in the use of hospital services for cancer care, by
institution in the public sector, may be due to changes
in a) the affiliated/registered/user population sizes; b)
geographic accessibility, sociocultural or economic; or c)
the epidemiological profile of the population. Thus, while
national health surveys do not reflect dramatic changes
in the epidemiological profile, they do document changes
in geographical and financial access to health services
though the Seguro Popular. This possibility leads us to
suggest that the observed increase in SSa/Sesa use is
mainly due to changes in public policy that resulted from
the implementation of universal insurance.
The length of stay by event and cancer type reflected
great variability. Leukemia care represented the highest
average number of patient days per event, the most
extreme range of variation, greater increases in hospital
discharges, and greater numbers of hospitalization days.
This finding could be due to the occurrence of complications, such as infections, anemia and thrombocytopenia,
that occur frequently during treatment and prolong a
patient’s hospital stay.27
The geographic distribution of cancer discharges is a
reflection of the availability of cancer care infrastructure
and is concentrated in states of Mexico City, Jalisco, Veracruz, Michoacan, and Nuevo Leon. These states have
State Cancer Care Centers (CECs), which are classified
as tertiary centers. They possess the capacity to perform
oncological operations, apply chemotherapy, and perform
histopathological diagnoses with radiotherapy units on
hand. This result is particularly interesting for further
investigation into issues of mortality and geographical
location regarding cancer care infrastructure. Moorin and
colleagues cite a large number of works that describe and
support the inverse relationship between distance services
and health conditions.28
Drawing on this experience, the utilization of hospital discharge records could be effective in monitoring
the progress of health institutions’ coverage such as the
Health Social Protection System (Seguro Popular), and the
level of utilization of services in the affiliated population.
Furthermore, the results can be used as inputs for the development of indicators to measure the success of health
care for different types of cancer and for subgroups by sex,
age and care institution. It is also critical to advance the
development of applications and algorithms to link data
from different sources to estimate survival, medical procedures and therapeutic paths. Likewise, these analyses
will be indispensable to the development of indicators of
quality of care and their costs.
The main limitations of the study lie in the quality
of the data and the definitions of the denominators. Gi151
Artículo original
ven that the administrative records of health institutions
could not be assigned denominators, it was not possible
to perform an analysis by age group, sex and institution,
although the overall rate by location could have been
calculated using the total population. In terms of quality,
a high percentage of deaths are still classified as tumors
of uncertain or unknown behavior, a number that should
decrease. Private sector data are only available as statistical
aggregates, which hindered their analysis and presented
inconsistencies in their breakdown by sex and age. Even
when the data were disaggregated at the patient level,
sector information only provides a minimum of information and prevents analysis of comorbidities and medical
procedures associated with hospital care. It would be
highly desirable if institutions in the public and private
sectors could provide more detailed information regarding hospital discharge records, incorporating the dates
of admittance and discharges, comorbidities and medical
procedures used, such as that published by the Ministry
of Health and the State Health Services.
The most relevant themes concerning utilization of
hospital services to address in future research entail the
assessment of treatment capacity and quality of existing
services based on the causes of hospital discharge.29
Declaration of conflict of interests. The authors declare that they have no
conflict of interests.
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